Last week, as the emergency department case manager, I was asked by the senior medical resident to see the patient in trauma bay 2 for discharge-planning needs. The resident told me the patient presented with anxiety and shortness of breath after being discharged yesterday. I went to bay 2 and saw a morbidly obese elderly woman sitting on the stretcher’s edge. Gray hair was unraveling from yesterday’s bun, and her extra large johnnie swept across her body and dangled to the floor. It partially hid her plugged tracheostomy tube held in place around her neck by tattered tracheostomy tape. Clearly distressed, she was crying, hyperventilating, rocking her large frame to and fro, and trying to speak through anxious stuttering.
I introduced myself and explained my role in her care. Immediately her voice became louder and with panic in her eyes she shouted, “No rehab. I’m not going to rehab.” Her fear was so real I wondered what the story was behind her adamant laments. Excusing myself while her primary nurse tended to her, I began to unravel the tale. She had been in the hospital numerous times recently for COPD flares, each time refusing all encouraged rehab placement efforts. Soon after each discharge home, she failed and returned to the hospital. Past case management and physician notes fit pieces of her medical history together, but none shed light on why she refused rehab placement.
The patient’s elderly mother, listed as her next of kin, is still active in her care. With the patient’s permission, I called her. My intent in speaking with her mother was to get a sense of who the patient was and how she lived her daily life. She spoke kindly of her daughter and how she wished her failing daughter would get better. She mentioned her daughter had been in several rehab hospitals in the past. One in particular, the Jewish Memorial Rehabilitation Center, helped her get back on her feet.
Armed with this information, I knew it was not fear the patient needed to conquer first. She needed to remember what was possible. I pulled up a chair beside her and asked her permission to have a talk. We spoke of good times past, about when she was able to breathe well, walk well, take pride in how she felt and looked. It was this memory that she needed to hold on to. Once she was able to do that, she was finally able to voice her fear of dying in a rehabilitation hospital.
During our conversation, I asked if she would go back to Jewish Memorial and let them work on getting her better. She said yes. The rest of my job was easy. I called the facility and after a discussion between multidisciplinary caregivers, they offered a bed and she accepted.
Case management is all about quality care and fiscal responsibility. I feel this exemplar conveys, with both goals in mind, how this miracle occurred.
